HIV-positive blood donors: can India afford to Inform?
1
379 1992 1993 Figure: IPTH(:t.-84) (A) and haemoglobin (0) ) A 62-year-old man with IgA nephropathy, on dialysis since April, 1977, was transferred to our unit in August, 1991. He received epoetin subcutaneously (1250 IU thrice weekly). In June, 1992, serum iPTH was 1812 pg/mL and intravenous alfacalcidol was started at 6 Ilg per week. Haemoglobin increased from 9-6 to 13-3 g/dL after 9 months (figure, lower), and serum epoetin went from 12 to 98 IU/L. Epoetin was withdrawn in February, 1993 (haemoglobin 14 g/dL). The improvement in haemoglobin concentrations associated with alfacalcidol allowed the withdrawal of epoetin. Hyper- parathyroidism is a resistance factor in epoetin treatment.2 Our data suggest a direct effect of vitamin D3 derivatives on haematopoiesis. The benefits of oral alfacalcidol in myelo- dysplastic syndromes without renal failure have been re- ported.3 The rationale was based on the data showing that vitamin D3 derivatives may induce cell differentiation and/or cell division. Similar effects have been reported for other lipophilic vitamin derivatives, such as retinoids.4 Àngel Argilés School of Medicine, University Montpellier I-UP 9008 CNRS, 34033 Montpellier, France Ronan Lorho AIDER, Montpellier Georges Mourad, Charles M Mion Department of Nephrology, University Hospital "Lapeyronie", Montpellier 1 Argilés A, Kerr PG, Canaud B, Flavier JL, Mion C. Hemodialysis and hemodiafiltration Ca kinetics, and long-term effects of lowering dialysate calcium concentration. Kidney Int 1993; 43: 630-40. 2 Rao DS, Shih MS, Mohini R. Effect of serum parathyroid hormone and bone marrow fibrosis on the response to erythropoietin in uraemia. N Engl J Med 1993; 328: 171-75. 3 Kelsey SM, Newland AC, Cunningham J, Makin HLJ, Coldwell RD, Mills MJ, Grant IR. Sustained haematological response to high-dose alfacalcidol in patients with myelodyspLastic syndromes. Lancet 1992; 340: 316-17. 4 Argiles A, Kraft N, Hutchinson P, Senes-Ferrari S, Atkins RC. Retinoic acid affects the cell cycle and protein metabolism in epithelial kidney cells. Kidney Int 1989; 36: 654-59. HIV-positive blood donors: can India afford to Inform? SiR-Proponents, such as your June 12 Round-the-World correspondent (p 1527), who wish to inform blood donors in India of their HIV status assume that this information would help positive donors to take precautions not to infect others. However, the group that is in greater need of testing is pregnant women. HIV prevalence in pregnant women is almost twice that in blood donors (per 1000)1: Moreover, the benefits of informing donors are uncertain because their behavioural pattern is unknown, whereas the spouse and unborn child and possibly others might gain from the pregnant woman’s knowledge of her HIV status. With respect to blood donors, there is a latency period between the acquisition of the virus and the appearance of antibody to HIV.2 Thus, a negative HIV status communicated to the donor may give them a false sense of security. The psychological effect on those who are misclassified as HIV positive should not be ignored. The average false-positive rate is 13%, as shown by confirmatory tests done in twenty-eight national reference laboratories.3 In India, the annual blood requirement is 4 million units, but only half this amount is collected (1 95 million units in 1989). Of these units, 0 76 million are obtained by private and commercial blood banks.’ The government of India envisages that HIV testing will eventually be done by these blood banks at their own cost. In a market economy, if the private blood banks choose to screen 0-76 million units of blood (at a rough cost of US$1-5 million), and subsequently destroy HIV- positive blood (purchased at a cost), it would be a big achievement. Furthermore, to expect them to do confirmatory tests, without any tangible profit to the blood bank, is wishful thinking. In this respect, it is noteworthy that, according to the Drug Controllers’ Office, 57% of government-managed blood banks are unlicensed. 4 We support the view that the objective of blood banks is to provide safe blood, and current testing policy of not informing the donors about their HIV status is realistic. Shashi Kant, L R Murmu Departments of Community Medicine and Surgery, All India Institute of Medical Sciences, New Delhi 110 029, India 1 Ministry of Health & Family Welfare. National AIDS control programme India-country scenario: an update. New Delhi: Government of India, 1993: 13. 2 Gellert G, Moore DF, Greenwood R, et al. More on office-based testing for HIV. N Engl J Med 1993; 328: 1717-18. 3 Snell JJ, Supran EM, Esparza J, Tamishiro H. World Health Organization quality assessment programme on HIV testing. AIDS 1990; 4: 803-06. 4 Ministry of Health & Family Welfare. National AIDS control progamme India-country scenario: an update. New Delhi: Government of India, 1993: 61-65. HIV testing: reduce costs by all means, but not at all costs SIR—As stated by Tamashiro et al (July 10, p 87), anti-HIV antibody screening costs can be reduced by alternative strategies based on one or several tests. The classical strategy involves a screening test which, if positive, is followed by a confirmatory western blot (WB) on a new sample. WHO has published guidelines on the interpretation of WB and on
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Transcript of HIV-positive blood donors: can India afford to Inform?
379
1992 1993
Figure: IPTH(:t.-84) (A) and haemoglobin (0) )
A 62-year-old man with IgA nephropathy, on dialysis sinceApril, 1977, was transferred to our unit in August, 1991. Hereceived epoetin subcutaneously (1250 IU thrice weekly). InJune, 1992, serum iPTH was 1812 pg/mL and intravenousalfacalcidol was started at 6 Ilg per week. Haemoglobinincreased from 9-6 to 13-3 g/dL after 9 months (figure, lower),and serum epoetin went from 12 to 98 IU/L. Epoetin waswithdrawn in February, 1993 (haemoglobin 14 g/dL).The improvement in haemoglobin concentrations associated
with alfacalcidol allowed the withdrawal of epoetin. Hyper-parathyroidism is a resistance factor in epoetin treatment.2 Ourdata suggest a direct effect of vitamin D3 derivatives onhaematopoiesis. The benefits of oral alfacalcidol in myelo-dysplastic syndromes without renal failure have been re-
ported.3 The rationale was based on the data showing thatvitamin D3 derivatives may induce cell differentiation and/orcell division. Similar effects have been reported for otherlipophilic vitamin derivatives, such as retinoids.4
Àngel ArgilésSchool of Medicine, University Montpellier I-UP 9008 CNRS, 34033 Montpellier,France
Ronan Lorho
AIDER, Montpellier
Georges Mourad, Charles M MionDepartment of Nephrology, University Hospital "Lapeyronie", Montpellier
1 Argilés A, Kerr PG, Canaud B, Flavier JL, Mion C. Hemodialysis andhemodiafiltration Ca kinetics, and long-term effects of loweringdialysate calcium concentration. Kidney Int 1993; 43: 630-40.
2 Rao DS, Shih MS, Mohini R. Effect of serum parathyroid hormoneand bone marrow fibrosis on the response to erythropoietin in uraemia.N Engl J Med 1993; 328: 171-75.
3 Kelsey SM, Newland AC, Cunningham J, Makin HLJ, Coldwell RD,Mills MJ, Grant IR. Sustained haematological response to high-dosealfacalcidol in patients with myelodyspLastic syndromes. Lancet 1992;340: 316-17.
4 Argiles A, Kraft N, Hutchinson P, Senes-Ferrari S, Atkins RC.Retinoic acid affects the cell cycle and protein metabolism in epithelialkidney cells. Kidney Int 1989; 36: 654-59.
HIV-positive blood donors: can India afford toInform?
SiR-Proponents, such as your June 12 Round-the-Worldcorrespondent (p 1527), who wish to inform blood donors inIndia of their HIV status assume that this information would
help positive donors to take precautions not to infect others.However, the group that is in greater need of testing is pregnantwomen. HIV prevalence in pregnant women is almost twicethat in blood donors (per 1000)1:
Moreover, the benefits of informing donors are uncertainbecause their behavioural pattern is unknown, whereas thespouse and unborn child and possibly others might gain fromthe pregnant woman’s knowledge of her HIV status.With respect to blood donors, there is a latency period
between the acquisition of the virus and the appearance ofantibody to HIV.2 Thus, a negative HIV status communicatedto the donor may give them a false sense of security. Thepsychological effect on those who are misclassified as HIVpositive should not be ignored. The average false-positive rateis 13%, as shown by confirmatory tests done in twenty-eightnational reference laboratories.3
In India, the annual blood requirement is 4 million units, butonly half this amount is collected (1 95 million units in 1989).Of these units, 0 76 million are obtained by private andcommercial blood banks.’ The government of India envisagesthat HIV testing will eventually be done by these blood banksat their own cost. In a market economy, if the private bloodbanks choose to screen 0-76 million units of blood (at a roughcost of US$1-5 million), and subsequently destroy HIV-positive blood (purchased at a cost), it would be a bigachievement. Furthermore, to expect them to do confirmatorytests, without any tangible profit to the blood bank, is wishfulthinking. In this respect, it is noteworthy that, according to theDrug Controllers’ Office, 57% of government-managed bloodbanks are unlicensed. 4
We support the view that the objective of blood banks is toprovide safe blood, and current testing policy of not informingthe donors about their HIV status is realistic.
Shashi Kant, L R MurmuDepartments of Community Medicine and Surgery, All India Institute of MedicalSciences, New Delhi 110 029, India
1 Ministry of Health & Family Welfare. National AIDS controlprogramme India-country scenario: an update. New Delhi:Government of India, 1993: 13.
2 Gellert G, Moore DF, Greenwood R, et al. More on office-basedtesting for HIV. N Engl J Med 1993; 328: 1717-18.
3 Snell JJ, Supran EM, Esparza J, Tamishiro H. World HealthOrganization quality assessment programme on HIV testing. AIDS1990; 4: 803-06.
4 Ministry of Health & Family Welfare. National AIDS controlprogamme India-country scenario: an update. New Delhi:Government of India, 1993: 61-65.
HIV testing: reduce costs by all means, butnot at all costs
SIR—As stated by Tamashiro et al (July 10, p 87), anti-HIVantibody screening costs can be reduced by alternative
strategies based on one or several tests. The classical strategyinvolves a screening test which, if positive, is followed by aconfirmatory western blot (WB) on a new sample. WHO haspublished guidelines on the interpretation of WB and on
